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甲状腺有肿块,应如何处理?

约有 5-10% 人口甲状腺会出现结节或肿块,是常见的疾病。但在单发性结节个案中,儿童约占 0.22-1.35%, 而成年人占 4%。单发性甲状腺结节鉴定的目标,是从众多甲状腺问题中分辨出真正的肿瘤。

简介

甲状腺结节在任何人口的发病率取决于不同因素,包括性别、年龄、饮食习惯、缺乏碘质的程度、及暴露于环 境性或治疗性辐射的机会。甲状腺结节多发生在女性身上,发病率随年龄增加,约有 5% 的女仕会于 60 岁出现甲状腺结节。此外,甲状腺结节与头颈位置接受的辐射剂量有直接关系(如二十世纪初治疗暗疮的方法)。

虽然甲状腺结节于儿童当中较少发病,但 15-20% 的结节有机会演变成恶性肿瘤,风险比成人高得多。大部份的儿童患的甲状腺结节都属良性,但相比成人,甲状腺癌对于儿童较具攻击性,所以及早作出准确的诊断是很重要的。

初步评估

一个全面的病史(包括颈部肿块、个人及家族)加上详细的头颈部检验都是重要的。颈部的疼痛、喘鸣、吞咽困难等症状都会增加临床的怀疑,但不能单靠这些症状作诊断。 只靠颈部外观的异样也不能准确预测肿瘤为恶性。

近期颈部大小的变化﹑肿块有否依附或入侵周边组织﹑及可触知的淋巴结病变,都意味著恶性的可能。声带痳痺并不一定与恶性肿瘤有关,此问题在良性肿瘤的情况也有机会出现。

单发性甲状腺结节的患者应作常规的甲状腺功能检查,但因为甲状腺癌患者的甲状腺功能一般是正常的,故这检查并不会发现其甲状腺功能有异。在这阶段不应以血清甲状腺球蛋白水平作参考,因为良性肿瘤亦能引致其水平提高。

表一 恶性与良性结节的症状

造影

不同的造影诊断各有优点及缺点。

表二 诊断甲状腺结节及颈部结构的不同造影技术
模式 优点缺点备注
超声波√ √√安全、有效、可区分肿块的大小、性质属固体或囊状发现「偶发瘤」!!有助指引细针穿刺活检
放射性核素安全

不能:
1. 清晰描画结节
2. 区分功能状态

碘123 (I [123]) 及鎝 99m( Tc [99m])
电脑断层扫描有助评估气管的入侵/压缩、纵隔肿块、反复发作的疾病不能使用碘化显影剂在初步调查中作用有限
磁力共振扫描? 不适用
正电子扫描?没指示作常规使用

细针穿刺活检 (FNAB)

鑑于其准确性、安全性及成本效益,细针穿刺活检是初步诊断甲状腺肿块的首选方法。 此活检是使用细针(-23G)的门诊程序,在超声波引导下进行较佳。细针穿刺得出的细胞学结果应被清楚分类,如图所示(表三)。

有一个研究复审了超过 28个系列的细针穿刺活检,其敏感性(83%)、具体性(92%) 及准确性(95%)都被评为远高于其他甲状腺的检查方式。使用较大的针有机会增加检验准确程度,但同时亦会增加血肿及损害周边结构的风险。

表三 细胞穿刺活检结果的分类

评估与管理

经过仔细的病史查问、临床检查及进行单发性甲状腺的细针穿刺活检后,可清楚得出一 个合适的管理计划,作观察或手术之用。若患者在细针穿刺活检中发现是良性病变,则可利用超声波观察一段时间。若确诊病变为恶性,便需要进行甲状腺切除手术了。

甲状腺手术的选择将另文讲解。

表四 不同结节的鑑别诊断

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